1. Distinguish which current reportable metrics are pertinent to the practice of anesthesiology.

2. Analyze metrics used in perioperative medicine.

3. Determine the impact of nonanesthesiologists on anesthetic care.

4. Discuss limitations of quality and outcome metrics.

5. Recognize the importance of communication, charting, delegation and supervision, and flexibility when the unanticipated occurs in avoiding malpractice lawsuits.

Making Quality Metrics Work for Your Patients and You
Daniel R. Brown, MD, PhD, Assistant Professor and Chair, Division of Critical Care, Department of Anesthesiology, Mayo Clinic, College of Medicine, Rochester, MN

Patient safety: concern about delivery of care stems from patient safety–related issues; despite ≈10 yr of intense activity and resource allocation, significant errors continue to occur; estimated incidence of medical harm in United States ≈40,000 incidents/day; various health care organizations, payors, and patient advocacy groups apply intense pressure to improve patient care

Public reporting of performance data: goal to improve patient care; reporting outcomes of care processes may 1) identify areas of reduced performance (to facilitate targeted improvements), 2) help maintain market share for specific health care services or providers, and 3) have direct financial implications (eg, reimbursement from Centers for Medicare and Medicaid Services [CMS]); however, recent article found reporting outcomes results in only small improvement in patient care; majority of efforts targeted locally, within given institution or hospital; reporting outcomes also has potential disadvantages (eg, decreasing time to antibiotic administration may impair ability to diagnose community-acquired pneumonia in emergency department)

Measuring quality of anesthesia care: mortality poor outcome measure for quality of care (difficult to identify outliers); other factors that affect mortality (eg, surgical care rendered, underlying physiology of patient) likely outweigh impact of anesthesia care; unclear whether outcomes should be risk-adjusted; quality of care during perioperative period typically measured by process adherence (eg, timing of antibiotic administration); attention to processes beneficial because of time-limited nature; processes may be more closely linked to performance (following proven beneficial interventions improves efficacy)

Current reportable metrics: use of metrics not confined to one group of health care providers; CMS “starter-set” of quality-of-care measures for patients with acute myocardial infarction (MI) proposed by US Department of Health and Human Services; available for review at www.hospitalcompare.hhs.gov; measures include aspirin upon admission and at discharge, β blocker upon admission and at discharge, and angiotensin-converting enzyme (ACE) inhibitor or angiotensin-receptor blocker (ARB) for patients with left ventricular (LV) systolic dysfunction; additional measures (depending on institution) include use of fibrinolytic agents ≤30 min after hospital arrival, percutaneous interventions ≤90 min after arrival, smoking cessation advice and counseling for current smokers, and 30-day risk-adjusted heart attack mortality; multidisciplinary intervention required to achieve stated goals; various organizations involved with quality-of-care initiatives overlap; many metrics found at CMS Web site http://www.cms.hhs.gov, including 2008 Physician Quality Reporting Initiatives (PQRI) for eligible professional quality measures (pertinent to cardiology in setting of acute MI; many metrics about diabetic care also reportable to CMS); primary care physicians and others can seek additional reimbursement from CMS if quality metrics met

Surgical-site infection (SSI): >500,000 SSIs yearly, according to some estimates; associated with increased morbidity, mortality, and cost; general principles of antibiotic prophylaxis—coverage for sites associated with infection; role of patient risk factors; treatment with antimicrobials effective for anticipated organisms; minimum inhibitory concentration (MIC) for pathogens of interest achieved or exceeded (in tissue and blood); appropriate timing of prophylaxis significantly decreases risk; barriers to timely antibiotic administration—delayed order for antibiotic (eg, providers may wait until patient in operating room [OR]), lack of awareness about goals, increased administration time (eg, increased with vancomycin, due to vasodilation), and pharmacy-related issues; initiatives—Centers for Disease Control and Prevention (CDC) recommendations for antibiotic prophylaxis include timing of administration of IV antibiotics to achieve bacteriocidal concentrations of drug in serum and tissues at time of first incision; Institute for Healthcare Improvement (http://www.ihi.org) endorses proactive changes to improve safety in patient care; goal to protect 5 million patients from medical harm over next 2 yr; focus is on preventing SSI by delivering reliable and appropriate care; appropriate use of antibiotics defined (administered ≤60 min before incision [except vancomycin and fluoroquinolones] in ≥95% of patients); other organizations support similar metrics

Central venous catheter: frequently placed by anesthesia provider; estimated 250,000 catheter-related bloodstream infections (CRBSI) yearly; attributable cost per infection estimated at ≤$25,000

CDC guidelines for prevention of CRBSI: increase awareness about causes and frequency of CRBSI; avoid femoral insertion site (subclavian may be superior to other sites); observe proper hand hygiene procedures; use maximal barrier precautions (recommendations include use of cap, mask, gown, sterile gloves, and large site drape); other recommendations applicable to anesthesia provider include skin antisepsis with 2% chlorhexidine, application of catheter site dressing, elimination of antimicrobial ointments and prophylactic antibiotics, and consideration of antimicrobial- or antiseptic-impregnated central venous catheters (if high frequency of CRBSI); daily needs assessment typically not performed by same person that placed catheter (especially not in OR setting); reasonable evidence suggests that following these guidelines reduces CRBSI; additional safety measures include ultrasonographic (US) guidance and vessel transduction

US guidance: metrics include use of imaging, evaluation of potential sites, and patency confirmation of selected vessel; available data suggest fewer mechanical complications, fewer failed insertion attempts, less time required to place catheter (compared to landmark studies), and fewer infections; US guidance beneficial (eg, for detecting thrombi and anatomic variations) for novice and experienced anesthesia providers; billing—allowable for US guidance if certain steps followed

Adherence to central line protocols: speaker’s department receives electronically generated reports (monthly) and information on CRBSI rates (quarterly); biggest problem assessing daily need for catheter; processes involve respiratory therapy, nursing, and physicians; “it’s a huge [part] of health care that is involved in meeting these patient metrics”

Perioperative glucose control: reportable metric only in cases of major cardiac surgery; <200 mg/dL in ≥95% of these patients; measurements taken on first 2 postoperative days; (obtained as close to 6:00 AM as possible); both values <200 mg/dL to meet criteria

Ventilator-associated pneumonia (VAP): affects ≈15% of intubated patients in intensive care unit (ICU); high mortality rates (up to 50%); processes proven to improve outcomes include elevating head of bed (semirecumbency), daily sedation holiday with evaluation for extubation, stress ulcer prophylaxis, and prophylaxis against deep venous thrombosis (DVT); speaker reports VAP-bundle compliance to state; speaker’s institution uses electronic rounds reporting tool managed by ICU personnel (nursing staff and house staff involved with patient care); if compliance issues identified by 5:00 AM, they are addressed during rounds; at 12:00 PM, data automatically sent to quality control office and bundled into reporting metrics sent out of institution; weekly feedback returned to medical director, attending physicians, and nursing leadership

Other aspects of care in mechanically ventilated patients: in patient with acute lung injury or acute respiratory distress syndrome (ARDS), studies show low tidal volume associated with improved outcome; standard of care of patients with ARDS in ICU; at speaker’s institution, automated system alerts respiratory therapist and summons physician to bedside when patient has arterial blood gas PaO2 /FIO2 (P/F) ratio <300 and chest x-ray shows evidence of lung injury, with ventilator peak pressure >35 mm Hg and set tidal volume >8 mL/kg ideal body weight

Anticoagulation, regional anesthesia, and catheter placement: American Society of Regional Anesthesia and Pain Medicine (ASRA) guidelines for anticoagulation instrumental in raising institutional awareness of bleeding complications with neuraxial catheters and anticoagulation

Malpractice Issues
Joseph A. Camarra, JD, Partner, Cassiday Schade LLP, Chicago, IL

Common themes: malpractice cases, in general, and anesthesia cases, specifically, involve communication, charting, delegation and supervision of functions in OR, and general category of “frozen thinking” (most commonly recurring theme in malpractice cases)

Standard of care: most jurisdictions define similarly; requires anesthesia personnel to carefully apply skill ordinarily used by reasonably well-qualified provider, under circumstances similar to those presented in case at issue; does not require perfection; bad outcome does not necessarily mean violation of standard of care occurred; legal standard actually set by health care professionals; in overwhelming number of malpractice cases, plaintiff required to have physician testify that defendant failed to meet standard of care; no shortage in number of physicians willing to testify for plaintiff

Charting: legal repercussions—hospital record (eg, preanethesia work-up, intraoperative record, postanesthesia care unit [PACU] record) becomes legal document in hands of attorney; most important legal document in case; should reflect what health care provider was thinking preoperatively, intraoperatively, and postoperatively; surprising how often it does not reflect thoughts and actions of provider; damaging evidence—in hands of plaintiff’s attorney, common claim is “if it’s not charted, it wasn’t done, or you didn’t think about it”; used as device to cross- examine provider; reviewed by experts and used (especially if record weak) as basis for criticism; thoroughness key—more complete and accurate record easier to defend; important to avoid jumping to conclusions in record; “if you fail to chart, you may wind up in difficulty in court”; in Illinois, Dead Man’s Act precludes party of interest in lawsuit from testifying about any conversation with or event occurring in presence of decedent because he or she cannot respond, but law does allow defendant to refer to chart; more thorough charting makes defense easier

Communication: “one of the biggest problems that physicians have”; nowhere in medicine is health care team viewed as single team more than in OR; patient assumes everyone knows one another, talking to one another, and will provide care as single unit; lack of communication causes teamwork to break down, resulting in negative consequences, both in OR and court room; case study of adverse outcome due to lack of communication

Delegation and supervision: anesthesiologist often delegates duties (including covering OR) to certified registered nurse anesthetist (CRNA) or resident because anesthesiologist responsible for patients in several rooms; appropriate only when anesthesiologist has assurance that delegatee has requisite expertise; however, attending anesthesiologist must be present during key parts of anesthesia procedure (note presence on chart), and must be immediately available if questions, concerns, or crises arise; often, attending anesthesiologist does not respond, and resident or CRNA overwhelmed; document on chart that discussion of informed consent took place before procedure; speaker believes patient entitled to know who will provide care in OR

Hypothetical case: preoperatively—105-kg patient with history of diabetes; planned surgery involved single-level lumbar discectomy and fusion; consent did not mention harvesting bone from iliac crest; anesthesia provider’s preoperative notes indicate surgeon has not ordered typed and cross-matched blood or cell saver; anesthesia provider advised room has been reserved for 3 to 4 hr; anesthesia provider never has discussion with surgeon about not ordering typed and cross-matched blood, cell saver, or length of procedure; patient has not ingested anything by mouth since midnight; surgery originally scheduled for morning but delayed until 1:00 PM; anesthesia provider evaluates patient preoperatively and places single peripheral 20-gauge intravenous (IV) line; patient receives 1 L of fluid while in preoperative holding area (inadequate, considering patient diabetic and had not taken in any fluids for past 12 hr); maintenance fluid 125 mL/hr; baseline hematocrit 42%; during procedure—surgery begins with surgeon harvesting bone from iliac crest, but anesthesia provider does not change anesthetic plan (ie, frozen thinking); worse yet, case continues for 8 hr; during procedure, surgeon requests cell saver (operated by nurse, who is backup for usual operator of device); anesthesia provider does not see visual signs of blood loss, but cannot see into incision; surgeon does not report unusual blood loss; total fluids administered include crystalloid (3 L) plus cell saver blood (925 mL); anesthesia provider does not obtain hematocrit or glucose measurement; during last 3 hr, patient becomes increasingly tachycardic and urine output drops; anesthesia provider perceives only mild dehydration (again, frozen thinking); estimated blood loss—charted/documented 4 times; 1) anesthesia record (1000 mL), 2) nurse using cell saver (1000 mL), 3) surgeon’s handwritten progress note (1500 mL), and 4) surgeon’s dictated operative note at end of case (1700 mL); neither anesthesia provider nor nurse has read manual attached to cell saver device; assumed 925 mL returned was total blood loss, but actual blood loss 1800 to 2000 mL; anesthesia provider recognized something amiss at end of procedure and decided not to extubate; postoperatively—anesthesia producer accompanied patient to PACU; in PACU, nurse did not hear anesthesia order for immediate complete blood cell count (CBC), blood gases, and electrolytes; not charted as “stat order” in record; ultimately, blood drawn and hematocrit of 19% noted; patient recognized as hyperosmolar and diagnosed with hypovolemia; anesthesia provider orders immediate delivery of typed and cross-matched blood (stat order not written in record, and nurse indicates not hearing order; untyped and uncross-matched blood would have been appropriate); outcome—ultimately, blood arrives, and 5 U placed (hematocrit 15.9%), but patient expires in PACU; cause of death hypovolemic shock, likely due to inadequate administration of blood and fluids during surgery

Lessons learned: do not take things for granted; communication between anesthesia provider and surgeon should occur before and during procedure; delegate responsibilities only to competent substitute; discrepancies in charting should signal need to communicate; be flexible when something unanticipated occurs (change previous thinking)